Mercy or Murder?

by DANIEL WALTERS & r & & r & & lt;span class= "dropcap " & P & lt;/span & rimum non nocere. First do no harm. That basic precept -- a Latin paraphrase of an aphorism from Greek physician Hippocrates -- has been a cornerstone of medical ethics for a more than a century.

But with the "Death with Dignity" act looming on Washington's November ballot, what exactly "do no harm" means has sparked heated debate within the medical community. Initiative 1000 allows adult patients with six months or less to live to request a cocktail of drugs to end their lives.

So does writing prescriptions to terminally ill patients for life-ending medication contradict the Hippocratic Oath or fulfill it? Answer: Depends on which doctor you ask.

Shane Macaulay, a Washington state radiologist and a member of the Coalition Against Assisted Suicide, sees I-1000 as a dangerous and unnecessary perversion of the traditional role of the physician as healer. "I will give no deadly medicine to anyone if asked, nor suggest such council," Macaulay says, quoting the Oath.

But for a second opinion, turn to retired cardiologist Thomas Preston. He points out that the Oath also swears to pagan gods and forbids surgery.

"Things have changed in the last 2,300 years," Preston says. "[But] we can all understand the cardinal ethical rule of 'do no harm.'" In some cases, he says, it's more ethical and merciful to help suffering people die.

"Medical ethics give a lot of weight to patient autonomy," Preston says. "What it comes down to is who should be allowed to make the decision -- the patient or the current laws."

Besides, he says, doctors have been helping their patients die for years. They can put them on morphine drips, they can induce sedation, they can cut off their ventilators or dialysis machines, and they can remove feeding tubes and IVs. The only real moral difference between that and "assisted-suicide," says Preston, is semantics.

Of course, sometimes in politics there's nothing more important than semantics. Groups on both sides claim the word "compassion" in their names. Initiative supporters prefer to call prescribing life-ending medication "death with dignity" or "aid in dying," complaining that the phrase "assisted suicide" conveys visions of Jack Kevorkian, irrationality and suicide bombers. Those against the initiative cry euphemism.

"If you're trying to sell something people won't buy, you have to sell it under a different phrase," Macaulay says.

Both supporters and detractors have accused the press of bias for using the "wrong" phrase. (For this article, The Inlander will follow Associated Press style by using "physician-assisted suicide," while noting two caveats to the phrase's traditional meaning: Only the terminally ill can receive the life-ending medication, and only the patients themselves -- not their doctors -- are allowed to administer it.)

Prevailing Winds

& lt;span class= "dropcap " & B & lt;/span & oth sides claim to have the greater force of medical opinion behind their position. Both have their fingers to the wind, but claim it's blowing in opposite directions.

Macaulay is quick to tout that 49 out of 50 state medical associations -- as well as the American Medical Association -- oppose legalizing physician-assisted suicide. "It's really kind of a fringe thing," he says.

Since the '90s, the question of physician-assisted suicide has been debated several times at the Washington State Medical Association's House of Delegates, says Deb Harper, vice president of the WSMA. Each time the majority of delegates landed firmly on the side of opposing assisted suicide legislation. Most recently, a resolution in October 2007 was defeated "resoundingly," Harper says.

The WSMA represents about 7,000 of the approximately 10,000 practicing physicians in Washington. It is "really very representative," Harper says.

Not so, says Preston. "I think the WSMA has misrepresented its members, and it's deceiving the public in what it's doing," Preston says. "They are not telling the public that its members and the public at large are supportive of approving the initiative being on the ballot."

For proof, he points to one of the WSMA's own surveys. In 2007, a WSMA member survey found that 50 percent of the members supported a measure similar to Oregon's Death with Dignity law, while 42 percent opposed it.

"Medical societies are never on the leading edge of where socially contentious issues go," says Oregon family doctor Nicholas Gideonese.

Several medical societies do support the initiative. Yeson1000.org touts the support of the American Medical Women's Association, the American Medical Student Association and the Washington State Public Health Association.

A Healer's Role

& lt;span class= "dropcap " & B & lt;/span & eyond simple endorsement numbers, much of the debate centers on the effect on the medical community. Kenneth Stevens, a radiation oncologist from Oregon who opposes physician-assisted suicide, has researched how such laws have affected doctors psychologically in Oregon and in the Netherlands.

"Doctors are not trained that this is how you kill a person," Stevens says. "Initially, there's a sense of responsibility."

Stevens says doctors in the Netherlands have formed support groups to help each other cope with the emotional fallout. He says that doctors deserve to feel some measure of responsibility for assisting their patients to end their lives

"It's like giving the patient a loaded gun and telling them not to use it until you leave," Steven says. In Oregon, he says, most doctors don't want to have anything to do with assisted suicide and most hospitals don't like to have it done on their premises.

"Trust is undermined when the doctor who is supposed to be healing you can take your life," Macaulay says. "We already have people that won't trust their insurance company. ... There's enough distrust in the system."

He also worries insurance companies may start subtly pressuring doctors to recommend physician-assisted suicide in order to save money. (I-1000 supporters counter this claim with a study in the New England Journal of Medicine showing that if insurance companies encouraged assisted suicide, the cost savings would be negligible.)

Several Oregon physicians say the law has had a dramatically positive effect on Oregon's overall medical care. As a family doctor in Oregon, Gideonese has prescribed life-ending medication for about a dozen patients. He says his peers have been supportive. The controversy around the law has turned attention to improving pain relief and end-of-life care, Gideonese says.

Before the law, patients would still talk to their doctors about suicide, Gideonese says, but with great fear on the part of both doctor and patient. He says Oregon's law has thrown open the corridors of communication so everyone can speak honestly about end-of-life issues.

The Prognosis

& lt;span class= "dropcap " & W & lt;/span & hile Gideonese celebrates the fact that doctors are more legally protected, Macaulay laments it. Macaulay says as long as the doctors follow the law and don't act in bad faith, they can't be sued for negligence or malpractice.

For a patient to be prescribed life-ending medication, they must have only six months to live, but prognosis is a very inexact science. Macaulay says that one of his allies against I-1000 was once told he had only six months to live. But now, two years later, the cancer is in remission. "Accidentally or carelessly costing people years of their life by erroneous predictions is a serious problem," Macaulay says in an e-mail. He complains that doctors won't be held accountable for this type of error.

I-1000 supporters say that under Washington's current laws, physicians already face a brutal dilemma: either break the law by secretly discussing suicide with their patient or allow their patients to continue to suffer.

Both sides do seem to agree that no matter what happens at the ballot box in November, the debate won't stop. If I-1000 fails, the proposal will likely come up again. And if it passes, the debate will drop from the Legislature down to the individual level, as each hospital, each doctor, each patient decides for themselves precisely what "do no harm" means.

Supporters maintain that the current standards for long-term care workers are embarrassingly lax, pointing out that currently most are only required to have 34 hours of training. That's far less, they say, than people who manicure nails, style hair or massage dogs.

Community Care Coalition of Washington, which opposes the initiative, complains that the requirements would drive up health care costs, create more bureaucracy and exacerbate an already problematic health care shortage -- all without any evidence that it would actually improve care. The measure is sponsored by a chapter of Service Employees International Union (SEIU) and critics suggest it is an organizing tactic by the union.

Naturally, the people at Yeson1029.org disagree with many of these claims. They say that increasing training will increase retention, thereby alleviating the shortage. Their "I-1029 Fact Checker" lists a number of studies they say show an increase in health care quality after caregiver-training requirements were stiffened.